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r � ] a FI <br /> f FOR OFFICE � � F�R OFFICE USE: <br /> I APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No,7S.-/D/l <br /> Date Issued..&--14.--2-4� <br /> j --------------------- -------- ------------ This Permit Expires 1 Year From Date Issued <br /> 2—ELeD--l7 <br />{ AppTication is hereby made to.the SE6n Joaquin Local Health District for a permit to construct and install the work herein described. <br /> F This application is made in compliance with County Ordinance No. 549 and existing.Rules a d Regulations. <br /> � /� S'6w JO �.c'�y ��d�Y CLQ G ,,.• - <br />' JOB ADDRESS/LOCATION.. ` .'" .�" .. - - -- <br /> CENSUS TRACT <br /> Owner's Name.... ....:.. - <br /> .. . . �OPhone <br /> .. S C�... <br /> P hone <br /> --------------- <br /> Address... .-- .. - ------ ---i Cit --- <br /> Zip--------------- ------- <br /> Contractor's Name.... 47� A_V17id y ... .S ..License e-�------ --- r� <br /> , <br /> Sr�� Phone --------- ------ <br /> Installation will serve: Residence,X Apartment House ❑ Commercial ❑ Trailer Court ❑ r <br /> Motel ❑ Other-------------------- ---------- ----•-------- <br /> Number of livingunits:. ... J <br /> � - -- -•-_--.-Number of bedrooms_..._] - Garbage Grinder Size................. ...............•........................... <br /> Water Supply: Public System and name_......._. S� J, R C. <br /> ---- ----- ----------- ----_ --- --- -----------------------------------_................... ,-----._.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam,] W <br /> • Hardpan ❑ Adobe ❑ Fill Materia! . .... ....If yes, type................................ <br /> O <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No 'septic tonk or seepage pit permitted if public sewer is available within 200 feet,} h <br /> t <br /> PACKAGE TREATMENT ( ] SEPTIC TANK . _ -----.-----•------•---. ------- Liquid Depth---------------------------' . <br /> 4 ( ] Size <br /> Capacity..fQQ___..Type--- c"-. A3�Material_. O/� --------No. Compartments........,---- <br /> --- <br /> .. . -----Foundation..-- b..............Prop. Line..s71---.-- <br /> •. Distance to nearest: Well................................. �. . <br /> LEACHING LINE [ ] No. of Lines .� -_'�._ ---------- Length of each line------------------------------Total Length .. ................................... <br /> gecl 'D' Box---/......:Type Filter Material.lWc-A......Depth Filter Material...._'07O ..............................L <br /> Distance,to nearest: Well........................... Foundation.----..------.---------.---Property Line_----------- ------- -------- --.� <br /> SEEPAGE PIT [ ] Depth--- .... . Diameter----------------------Number----.--------------------------- Rock Filled Yes ❑ No [} <br /> WaterTable Depth---------------------------------- ------ ---------------Rock Size-...-..-. --.....------_----------------- N <br /> Distance to nearest: Well-------------...............................Foundation...................... ...Prop, Line......................-..... <br /> 1 <br /> REPAIR/ADDITION (Prev. Sanitation Permit#____________ __ . - --...Date-....-..:..._._-_____-- ____ -- <br /> Septic Tank (Specify Requirements).......- -------- ------ - --------------------__....... ------......r <br /> Disposal Field (Specify Requirements)-- ---- ------------= -•---------- .......... ----------•------ . .......------------------ - --- ---------------------- `.. <br /> .... -----------•------------------- ------ -------------------------- •-•--............ -•--- ---- - ....... Vl <br /> ---------- --------------- ---- - <br /> .(Draw existing and required addition on reverse side) ts <br />` I hereby certify that I have prepared this application and that the work will be done in accordance with San' Joaquin County <br /> Ordinances, State Laws, and Rules and Regulations of the San Joaquin-Local Health District, Home owner or licensed agents <br />` signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as <br /> to become subject to Workman's Compensation laws of California." <br /> Signed...... . N__- b ...5�/ - ----------. .Owner <br /> By................� ....------...........Title..Title._. ............... ............ <br /> [ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__. .... ......... ......DATE .Z1:---�T�... ............ <br /> DIVISION OF LAND NUMBER.,.............. ..........................DATE......._........__.-------- <br /> ADDITIONAL COMMENTS........... ... ........ . ----_-- ------------- ------. <br /> --- ---------------- - ............. ----------------- ------ .......... ---..-----.....-- ----- . ------.........--.---.. • • -- ------------- ............ •.. ...................... <br /> -------...--------------------......----------------- - - ---- ---- ---- ----- ------ - ---------- -------- <br /> Final Inspection b --- --- <br /> EH 13 24 SAN JOA IN LOCAL HEALTH DISTRICT 677 REV. 7/7o 3M <br />